2.50
Hdl Handle:
http://hdl.handle.net/10755/344170
Category:
Abstract
Type:
Poster
Title:
Computer vs. Paper: Trauma Resuscitation Flow Sheet Design
Author(s):
Root, Natalie
Lead Author STTI Affiliation:
Non-member
Author Details:
Natalie Root, MSN, RN, CEN, CPEN, natalie.root@mwhc.com
Abstract:
Evidence-based Practice Abstract Purpose: Computerized documentation has proved to be essential to patient care documentation, However during fast paced critical situations difficulties arise. The objective of this project was to create a paper trauma resuscitation flow sheet. Three major goals were established. First, to create a trauma resuscitation flow sheet that would accurately and completely capture the clinical care provided during a trauma case. Second, was to make sure that it encompassed the required items for the State Trauma Registry, and lastly it needed to be easy to navigate in effort to increase the speed at which charting occurred. Design: This project was a staff led quality and performance improvement project. Setting: A Community Level II Trauma Center in a non-for profit hospital. Participants/Subjects: TRN team leaders, ED CNS was the team facilitator. Additional members were trauma surgeons, trauma intensive care nurses, nursing leadership, and business manager. Methods: The ED had an established team called the TRN team. This is a Shared Governance team in which the nurses are integral in leading the changes to trauma care provided in the ED. Prior to the transition from one electronic medical record to the new one, an evaluation the documentation of trauma care was completed. The review was led by the CNS, TRN’s and Trauma Service Leadership. The original EMRS had a customized template that assisted the nurse assigned to document trauma care. It also contained a template that contained fields for documentation that met the requirements for Virginia State Trauma Registry. Upon reviewing the new EMRS the team felt that the trauma electronic charting was lacking pertinent aspects required for the registry and was not easy to navigate. To maintain Level II Trauma Center Verification a list of required documentation items must be completed. The team identified the need for trauma documentation redesign. Identified documentation issues were discussed at our Trauma Core Nurse meetings. The team determined to provide the best quality and safe care to our trauma patients a customized Trauma Resuscitation Flow Sheet would be needed. They assembled a list of chart requirements, researched other centers charting process. Multiple drafts were established and shared with the bigger team. Once completed the flow sheet underwent multiple trial tests then education for staff followed. Results/Outcomes: Five key components of the chart were used to evaluate the efficacy of the change from computer to paper charting. Through 100% trauma open chart review, the extent of the omission of the State Registry. The team looked at activation time, triage time, EMS name and temperature. The team compared pre implementation of paper to post implementation of paper charting. “Activation Time” is a required item to report in the Trauma Registry. The “Activation Time was missed an average of 47% of the time was reduced to 1%. The “Initial Temperature” is both a required registry component and a highly clinical data point. The switch from computer to paper decreased our missed charting to 1%. Implications: Patient safety was increased through improvement of communication. Omitted information was now contained in the medical record.
Keywords:
Computer vs. Paper; Flow Sheet Design; Trauma Resuscitation Flow Sheet
Repository Posting Date:
4-Feb-2015
Date of Publication:
4-Feb-2015
Conference Date:
2014
Conference Name:
2014 ENA Annual Conference
Conference Host:
Emergency Nurses Association
Conference Location:
Indianapolis, Indiana, U.S.A.
Description:
2014 ENA Annual Conference Theme: Safe Practice, Safe Care. Held at the Indiana Convention Center
Note:
This is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.

Full metadata record

DC FieldValue Language
dc.language.isoen_USen_GB
dc.type.categoryAbstracten_GB
dc.typePosteren_GB
dc.titleComputer vs. Paper: Trauma Resuscitation Flow Sheet Designen_GB
dc.contributor.authorRoot, Natalieen_GB
dc.contributor.departmentNon-memberen_GB
dc.author.detailsNatalie Root, MSN, RN, CEN, CPEN, natalie.root@mwhc.comen_GB
dc.identifier.urihttp://hdl.handle.net/10755/344170-
dc.description.abstractEvidence-based Practice Abstract Purpose: Computerized documentation has proved to be essential to patient care documentation, However during fast paced critical situations difficulties arise. The objective of this project was to create a paper trauma resuscitation flow sheet. Three major goals were established. First, to create a trauma resuscitation flow sheet that would accurately and completely capture the clinical care provided during a trauma case. Second, was to make sure that it encompassed the required items for the State Trauma Registry, and lastly it needed to be easy to navigate in effort to increase the speed at which charting occurred. Design: This project was a staff led quality and performance improvement project. Setting: A Community Level II Trauma Center in a non-for profit hospital. Participants/Subjects: TRN team leaders, ED CNS was the team facilitator. Additional members were trauma surgeons, trauma intensive care nurses, nursing leadership, and business manager. Methods: The ED had an established team called the TRN team. This is a Shared Governance team in which the nurses are integral in leading the changes to trauma care provided in the ED. Prior to the transition from one electronic medical record to the new one, an evaluation the documentation of trauma care was completed. The review was led by the CNS, TRN’s and Trauma Service Leadership. The original EMRS had a customized template that assisted the nurse assigned to document trauma care. It also contained a template that contained fields for documentation that met the requirements for Virginia State Trauma Registry. Upon reviewing the new EMRS the team felt that the trauma electronic charting was lacking pertinent aspects required for the registry and was not easy to navigate. To maintain Level II Trauma Center Verification a list of required documentation items must be completed. The team identified the need for trauma documentation redesign. Identified documentation issues were discussed at our Trauma Core Nurse meetings. The team determined to provide the best quality and safe care to our trauma patients a customized Trauma Resuscitation Flow Sheet would be needed. They assembled a list of chart requirements, researched other centers charting process. Multiple drafts were established and shared with the bigger team. Once completed the flow sheet underwent multiple trial tests then education for staff followed. Results/Outcomes: Five key components of the chart were used to evaluate the efficacy of the change from computer to paper charting. Through 100% trauma open chart review, the extent of the omission of the State Registry. The team looked at activation time, triage time, EMS name and temperature. The team compared pre implementation of paper to post implementation of paper charting. “Activation Time” is a required item to report in the Trauma Registry. The “Activation Time was missed an average of 47% of the time was reduced to 1%. The “Initial Temperature” is both a required registry component and a highly clinical data point. The switch from computer to paper decreased our missed charting to 1%. Implications: Patient safety was increased through improvement of communication. Omitted information was now contained in the medical record.en_GB
dc.subjectComputer vs. Paperen_GB
dc.subjectFlow Sheet Designen_GB
dc.subjectTrauma Resuscitation Flow Sheeten_GB
dc.date.available2015-02-04T11:27:44Z-
dc.date.issued2015-02-04-
dc.date.accessioned2015-02-04T11:27:44Z-
dc.conference.date2014en_GB
dc.conference.name2014 ENA Annual Conferenceen_GB
dc.conference.hostEmergency Nurses Associationen_GB
dc.conference.locationIndianapolis, Indiana, U.S.A.en_GB
dc.description2014 ENA Annual Conference Theme: Safe Practice, Safe Care. Held at the Indiana Convention Centeren_GB
dc.description.noteThis is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.en_GB
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